S 0085 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-EL.EC1'RICALrrARY
RMIT NO.
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BUILDING DIVISION APPLICATION/PERMIT TING PROJECTBING- IDENTIFIC G V V QST
p BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: NR DO'S 6 �og63 , API'L�ON SlJ11MITT .IlAll111 UIID 0 V IAO VlLLA4OWNIiR:S NAMIi: 1IIUNF:: C(NTRACTOR'S NAM;: G'd QST. NG Y](' LIC NO: CONTROI.d
V 54
�ARCHLL /ENGI fiER: LICN - A>D ESS:
ij ' 6
CONTACT: I'HONe: —/ BUILDING PERMIT INFO
L�1 - rConsultant Fees Paid by Applicant(Initial) B E :c PLUMB MECH
-571 ON El E]LICENSED CONTRACTOR' ,S DI.ARAIION Q'FY. ELEC-rRICPERMfF FEE J O $CRIPTION
I hereby allirm mal 1 ain rete,d coder no vinch,of Chan(enminencing
,0C with Section 7mNB of Divlstun Jofthe Nusinez.and Pro .i/+n2C erre mylicemeis RFSIDENTIAI'
cwz " full force and eRcct. r PERMIT ISSUANCE ❑SF)WL ❑KI'fCH1iN RfiMODIJ.
W-F- Li,,nm Cl' s Lich
HGi p;qu Cnmramnr 1 APPLIANCES-RESIDCNTInL ❑ADDITION ❑PLUMNING RE-PIPE
ARCHI'1'[CT'S DECLARA ION PANELS ❑h1Ul:fl-UNIT' ❑STRUCIIIIts\L
~y Z I un mm�d my plans shall Fe usW as public¢cads MODIFICATION
ZOZyC UP 10200 AMPS El INTERIOR El CHIMNEY REPAIR
o zz ,,ty Licensed Pmfexsinnal 2111-IIXX)AMPS IMPROVEMENT []SWIMMING POOLS
9X xE 1 OWNER-IIUILDER DECLARATION OVER I(NIfIAMP$ ❑BATII Rh:MODIiIAIifiPAIR ❑DEMGhH'IQN
aG''CL a e,' 1 hereby viii...Thal 1 vat uempl Gem the CnnlmatOr',license Law Ibr the Cl 09'HER
3 LL F- following reason.(Section 7031.5,Bminess mJ Professions CeWc:Any city or roomy SIGNS ELECTRICAL.
y which requires v potent to construct,alm4 improve,demolish.or repair any slmeture
�asG� print to, 'nc is,rotates the ppl tf r suchperoult rile a signed stnment SPECIALCIRCUIT/MIS
�y pro In .. rt 'hp ld ( r t '1 1 (Chapter9 OC ML:
MERCIA
ad (,onmennngwth Scene 70UIIId Division 3 of the Business std Pmenine,Code),), TEMP.MET- IT IN
a dx o C that he is exenpl merefrmn And the basis far the allegN exemption.Any swimmer of El NEW BhUG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by any vppliclem for a Perms subjects the anplicom to a civil pcnalry of POWER ❑'1'I' ANT ❑FOOD SERVICE
1.. not more than Lee hundred dollars(S50(b. 1111PROVEMENT p
C'ZyyQ 01.uxn.orrof the po,Pcrl,nf my cnployces with wugcn ns(helr.vohe cootpnrsvlom, SWIMMING 01,ELL IC �/ CATS FMISNtdG
d will Jo the work.and theswcmm is nor intended or Offered our sale(Sec.7194,Business OI118R
W3 w and I'rofcssions Code:The Contractor's License law does not apply to an owner of OUTLETS-5 W ITCI .:-FIXTURES
pmpeny who builds or improves mercon,and who does such work himulf or Through 1.erlXi B l
his own employees,provided that such impmvcommol a not intended or offered for NEN'RESI NT L ELEC IR b .
sole ll,hnwevcq the buildingerr lntpmvcmem ix sold within oncywrofutmpletlo0 the SQ.F..FLOOR AREA $/SQ.FT.
o rbuildcr will have one border of p ming mm he did nor build or improve for pun- y�
wnc P pp
Post o (y 1.. W
❑La,owner of he pec.704 vat exclusively smmmafng with licensed e'enrmmars m
cenetmct the does
project(Sec.7044.w nerofs and Professions Ctdc:)Theves it nAs Li- JUN c ceLnwdocsnmuhPlyntun with
acofproperty whored pursuant to the Coreon,end QTY. PLUMBING PERMIT ��
who contracts for such pmjcro with v mmmator(v)licensed pursuant to the Contractor AI"/Xy�
License law. PERMIT ISSUANCE ��II[[�(/4(�
El I am exempt umler Sec. .B&P C fonhis reason ,� r
ALTER-GRAIN&VENT'-WATER LEA) ��� CfOI ION
Owner Gum
• WORKER'S COMPENSATION DECLAIM ION HACK FLOW PRO]fiCT.DEVICIi
I hereby pendlyofperjury One of arefollowingI declarations:
I have and will mvimam aCcnircatc of Cnnremtoself-insure En Worker's Compcn- DRAINS-FLOOR.ROOF ARIiA,COND. STORIES TYPE CONSTRUCTIOt
inion,m'provided f r by Section 37M of the Labor Code,file the Perecu me of the
work lin which this pen n
of is is.sueA. FI%TURKS-PLN TRAP
I have unit will eaten n Wn kc,,Compenmtinn Insnrmct.as required by Section GAS-EA.SYSTEM- INC.S OUTLETS
]Toth Uf me Wbo, cC fonhe'if yrm� ecufine work for which Its P< J OCCUR P NN
My Wnrle, j;oJpp `I�4n' 1e `r and Policy S � � GAS-IiA.SYSTENTOVER]IEA)
Currier:__IJTp_l f g�Tl AA Policy No.:
CER"FI FICATE 017 :XEMen[ON FRO WORKERSGREASEIINDUS'I'RI.WASS'E IN'IPRCEPIOR
COMPENSATION INSURANCE 3 .1 GDIVISIUN FEES
(Thlesectionneed not Mcontpletedifthep mirisforunehuWM dollars(SLW) GREASEIRAP PI.ANCHEC
or less.)
(certify that in the operforafthwork for which thisemitJ.lshnll SEWIik-SANTARY-STORM IiA 200 IT. ENERGY
nt employ ny noncom in anym,hu,nn usnt hee.nmwdhc Worke,,'
Cnmpco-
Z ration lases of Culili+miz.Dam WATER BEATER WNENTMI-ECfR GRADING Ji
ZO AppficxNOTJCm l
rNa NUTICE ah APPLICANT:r,Co malting this Certificate of Exemption,you should WATER SV$TLM/I'ktiATING SUITS FEE
bceame r comply
he Wath pr Viso u,or this ero isiam of me ,nbnr Cale,you mu>I
!nhwhh comply with such provisions or this Pcnnil shall he devnmd thanked. WA'Flilt SERVICE
k p
CONSTRUCTION LEi`H)ING AGENCY
NEW RISIDEM1TIAI,PLMB. SQ.ITE LAID
[)—air Rte it of
1 hereby affirm that them is a construction lending agency for the a donnaxe of
W O the work for which this permit is i...ed(Sec.3TP7,Civ.C.) TOTAL:
O U Lender's Name TOTAL:
rLenders Adcl BUILDING FEE
W I sonify mat 1 have reactions application and state that me above art ..ion is
a.F (n correct,l agree m comply with all city and county nedinames and stare law,relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z M+ilding conslnlerum,and herebyomhmoic representatives oflhis city a+enter upon the
uMrvclncntio ced Pmpony li+r inspmti nPuq+encs. PERMIT'ISSUANCE HLEC'FRIC FIJI
(We)agree I Indemnif and keep harmlev 16e City of Cupcnino against
liabilities,judgm s nodexpe its which may in anyway accrue agi insisaid City ALTER OR ADD'IO MECH. PLUMBING FEE
inconsequence fire ct Ong eftyynnAt.
APPLICANT BIDE ). NNTLLCOMPLYWIT I LL ON-POINT AIR HANDLING UNIT RG 10,000 CFF) MECHANICALI'EE
SOURCER 'ULA('
AB HANDLING UNIT(OVEk 10h(XX)CFM) CONS9'RUCfION TAX
Signorine dAppliciniCimle, Date EXHAUST FOOD(W/DUC) DOUSING MITIGATION FEE
IIAZARIX MATERIALSDISCLOSURE
lhcuppllevnl or lianre buildin6 acuupvnr stem nr boodle beer.. m, oterivl I IF.AIING UNIT TIR I I(a)com It'IVI
ax dein by the Cupertino Municipal Cada Chapter 9.12,and the Health an Safety BEATING UNIT(OVER 100.000 B'TU)
Code.Section 25532m)? PAID
C]Yes ❑No VLNTILATION PANS INGLE RESIDI Dane Receipt rl
Will rbc applicant or future building occupant use equipment or devices which BOILER-COMP(]IIP OR I00,1%X1 B'DI)
cont hamedous air contaminants as defined by the Bay Area Air Quality Management IOTA h:
District? BOILER-COMP(OVER L00.000 BTU)
❑Yes 0N
AIR CONDITIONIift ISSUANCE DATE
1 buvc read the Cork.Se non,255 5.2553rerrls under Chapter d is 0l the Cull"
fi+mia
building
&Scurry tlySections 255115,relay and reibil.I to beefnnd mar Of me NEW RISIUIiNT1Al.MECH. SQ.17.
of Cheng dos not currently must have. met p that o relay ce of.bllity nt notify the o capant
enc..
of the reyui¢ments which must he mel prior m issuance ill a Ccnilicam of(kcupvncy.
Owner or auffinnued agent
Doc TOTAU ISSUED BY:
OFFICE